ABSTRACT
Hospitals across our nation are seeking to implement models of care that meet the primary goals of Quadruple Aim: Improved population health, cost-effective care delivery, and patient and provider satisfaction. In an effort to address the Quadruple Aim and our patients' care needs, Hamilton Health Sciences (HHS) embarked on a model of care delivery redesign, beginning with nursing care delivery. From 2013 to 2018, 12 clinical programs at HHS implemented the Synergy Model with its accompanying synergy patient needs assessment tool for nurses to objectively assess patients' acuity and dependency needs. Data on patients' priority care needs were used to inform a nursing model of care redesign at HHS, including skill mix and staffing levels. This five-year project was an organization-wide quality improvement initiative. As part of the evaluation, HHS leaders partnered with health services nurse researchers to conduct a mixed methods study. This paper describes the evaluation outcomes from the qualitative component of the study, which included interviews with clinical nurse leaders and direct care nurses. Data were analyzed using descriptive thematic analysis. Some key findings were increased nurse awareness of patients' holistic care needs and leaders' capacity to plan staffing assignments based on patients' priority care needs. Themes helped inform recommendations for key stakeholders, including nurse leaders and direct care nurses.
ABSTRACT
BACKGROUND: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. OBJECTIVE: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). METHODS: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. RESULTS: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. CONCLUSIONS: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.
ABSTRACT
PURPOSE: Some severe complications during percutaneous dilatational tracheostomy (PDT) may be related to poor visualization of tracheal structures. Subjectively, the bronchoscopical view obtained via a laryngeal mask airway (LMA) seems to be better than that obtained with an endotracheal tube (ETT). In this prospective, randomized study, we compared LMA and ETT as the ventilatory device during PDT mainly with respect to visualization of tracheal structures. The quality of ventilation and airway-related complications are also reported. METHODS: In this prospective, randomized study, PDT was performed using an LMA (n = 33) or an ETT (n = 30). Quality of ventilation and visualization of tracheal structures (thyroid, cricoid, and tracheal cartilages) were rated as follows: very good (1), good (2), difficult (3), and not possible (4) with LMA/ETT. A rating of 4 required the alternate airway. Groups were compared using the chi(2) test. RESULTS: Visualization of tracheal structures was better with the LMA: ratings were 1 or 2 in 94% of patients with an LMA, compared with 66% of patients with an ETT (P <0.05). Visual control during puncturing the trachea was 1 or 2 in 97% of patients using an LMA and 77% of patients for an ETT (P < 0.05). A rating of 4 was assigned to 1 patient with an LMA and to 3 patients with an ETT. Hemodynamic variables were similar in both groups. Blood gas analysis during PDT showed decreased Pao(2) in both groups, and increased Paco(2), which was more pronounced with an ETT compared with an LMA (59 +/- 14 mm Hg and 51 +/- 11 mm Hg [P < 0.05]). In the ETT group, 2 patients were extubated accidentally, and in another patient, the bronchoscope was damaged because of insufficient visualization of the tracheal puncture site. CONCLUSION: The LMA technique showed definite advantages regarding visualization of relevant tracheal structures and the dilation process compared with an ETT. This may be especially relevant in the hands of inexperienced intensivists and in cases of difficult patient anatomy where improved structural visualization optimizes operating conditions.
